Healthcare Provider Details

I. General information

NPI: 1861259004
Provider Name (Legal Business Name): HUMAN WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 BROADWAY ST STE 301
LAGUNA BEACH CA
92651-4328
US

IV. Provider business mailing address

30025 ALICIA PKWY # 635
LAGUNA NIGUEL CA
92677-2090
US

V. Phone/Fax

Practice location:
  • Phone: 949-342-6011
  • Fax:
Mailing address:
  • Phone: 949-342-6011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DR. COURTNEY M TRACY
Title or Position: FOUNDER
Credential: LCSW, PSYD
Phone: 949-342-6011